Published: 07/03/2002, Volume II2, No. 5795 Page 28 29
Poverty and ill-health sit side by side. If anyone any longer entertains doubts about this, they can do worse than look at Bradford's population,40 per cent of whom are classified as deprived.Twelve of its inner-city wards fall within England's poorest 10 per cent; one is ranked second and one fifth most deprived.The effects of this level of poverty are witnessed in the health statistics: the incidence of diabetes is more than four times the national average; death from heart disease is twice the national average; people in Bradford die younger - death rates in the most deprived areas are 50 per cent above the national average.
In the inner city, most people come from South Asian backgrounds.Their ethnicity must be, and is, acknowledged by those planning for the health and wellbeing of all.This is an area where there is much energy and initiative - both in primary care organisations and in its citizens more generally.But this sits beside a strong awareness of social exclusion.The resulting tensions were manifest in the riots of 2001 and have been described in the Ouseley report.
1Primary care is a very visible service in these communities; the health centre on the street corner, the GP surgery in a row of terraced houses.Most people go to their doctor. If you want to consider their wellbeing, as well as treating their illness, then this is a good place to offer a service which recognises that poverty and social exclusion are bad for your health.
There is some national support for this approach:
The Acheson report noted problems in uptake of welfare benefits.About 1 million, roughly one in four, do not claim support to which they are entitled.
2A core objective of primary care groups and trusts is to improve health and address inequalities.This includes engaging with social, economic and environmental influences.
3The NHS plan highlights the need for integrated health and social care provision, 'recognising that good health also depends upon social, environmental and economic factors such as deprivation, housing, education and nutrition. . ' 4One way to bring together the agendas of poverty, health and social exclusion is to place welfare advisers in primary care centres.One such scheme raised over£500,000 for people in inner-city Bradford during its first 10 months.
Bradford is not the first city to place welfare advice in primary care settings.Projects are widespread, and elsewhere we have summarised their method of work and achievements to date.
5Here we offer a six-step model as a template for similar developments in primary care and then report initial results of the Bradford project, both in terms of money raised and in service recipients'and service providers'perception of the strengths of the scheme.
Bradford City primary care trust was awarded funding for three years from the health action zone innovations fund to set up the Health Plus project.An integral part of HAZ funding supported an evaluation.
In March 2000, six advice workers started placements in GP practices.Thirty-one (out of the total 44) practices within the Bradford City PCT area were allocated an advice worker for one session each week.Each advice session lasts three hours.During that time, typically, four people are seen.
Advice workers are often generalists, but some problems require specialist help - for example, representation at tribunals.
In this Health Plus project, four specialists were appointed to deal with complex issues relating to benefits, debt, employment and immigration.
In the first 10 month (March-December 2001),849 people were referred.Almost a third came from GPs - other referrals came from nursing staff, receptionists and practice managers.
One in five approaches came from the public, often at the suggestion of family and friends.Most people seeking advice were of Pakistani ethnic origin (60 per cent), slightly more than the overall proportion in the Bradford City PCT area.Sixty-one per cent were female.Only 7 per cent were employed full-time, and 31 per cent were disabled.The main reason for referring (63 per cent) was for benefits-related advice.
The annual amount of any benefits awarded or augmented is recorded along with 'one-off payments'and backdated benefits.
Figures on income generated are only recorded for the 382 cases that have been closed.Two-thirds of these closed cases (255 out of 382) had seen extra income obtained - a total of over£500,000.
One can project likely gains of perhaps another£500,000 for cases still under consideration.Comparable projects in other parts of the country have generated similar amounts of unclaimed income.
5The following three case studies indicate the circumstances in which this income is generated.
Andrew,53, lives alone.He suffered brain damage in an accident and has poor memory and reading difficulties.He was in rent arrears and his housing association obtained a possession order.The association contacted Andrew's GP to see if he could help, and the GP referred Andrew to the advice worker, who in turn contacted the housing benefit office. It transpired that Andrew had been ignoring letters from them - because he could not read them.As a result, his benefit had been stopped and rent arrears accumulated.
The housing association agreed to allow time to sort out the housing benefit claim, and the advice worker helped Andrew apply.Andrew was also told he was entitled to severe disability premium, and the advice worker wrote to income support to claim this.The housing benefit office paid the rent arrears, and eviction was averted. Income support now pays£41.75 extra per week and Andrew received a backdated payment of£7,000.
Zahra,25, has multiple health problems requiring frequent hospital stays.She lives with her parents.A year ago, she was too ill to attend her disability living allowance appeal and had not had any benefits since then.Her parents - full-time carers - received no help to take care her.The district nurse referred Zahra to the advice worker who helped her to claim DLA.
Supporting letters were obtained from her hospital specialist and the district nurse.
Zahra received the higher-rate DLA (£93.95 per week), and an increase in income support (£11.05 per week).Zahra's mother also received invalid care allowance and an increase in income support.
Margaret,73, has health problems, including arthritis and breathing difficulties.She lives with her 38-year-old daughter.
Margaret had applied for attendance allowance twice in the past but was turned down.She did not appeal on either occasion.The advice worker filled in a new application for attendance allowance, including detailed information on her health and social circumstances.
Attendance allowance was agreed at£55.75 a week.
Margaret's daughter then became eligible as a carer to apply for invalid care allowance.
Service users were asked for their views and said they found the scheme convenient and useful.Comments included: 'The advice has helped me a lot. It is convenient to come to the surgery and also to receive advice in my own language.'
'I received DLA, income support and a budgeting loan.Though my health problems are the same [arthritis, back and joint problems] my stress has reduced immensely allowing me to cope a lot better.'
'The advice worker has kept in touch - ringing to see how we are and if we had received replies to our applications - giving a sense of caring.'
Advice workers stressed the importance of promoting the service to practices, including offering initial training for staff about appropriate referral. In some cases it was felt that commitment from practice staff to the service was lacking.This was reflected in number and type of referrals.The co-operation of reception staff is crucial.One advice worker described what constituted a good and a bad GP practice: 'Good: took time to get to know me personally, and my role; they ring me to check if the referral is appropriate.Bad: they put me in a room; reluctantly make appointments; There is no interaction with staff; they're not interested in my role and how it might benefit patients.'
Inter-agency working between health and advice services made making health-related benefit claims easier and served as a resource for the primary healthcare team.Accessible and relevant services, delivered through primary care, help generate a sense of social inclusion.Having more money also helps your sense of being a part of a community.
Peter Greasley is research fellow and Neil Small is professor of community and primary care, school of health studies, Bradford University.
REFERENCES
1Sir Herman Ouseley.
Community pride, not prejudice.Bradford Vision, 2001.
2Acheson D. Independent inquiry into inequalities in health.The Stationery Office, 1998.
3Department of Health.Primary care groups: delivering the agenda.The Stationery Office, 1998.
4Department of Health.The NHS plan.The Stationery Office, 2000.
5Greasley P, Small N.Welfare advice in primary care: a review of the literature.Nuffield Institute for Health Portfolio Program, 2002.
Key points
Putting six advice workers into general practices for three hours a week over 10 months resulted in£500,000 being identified in benefits for patients.
Many referrals came from GPs, but patients referred themselves in a fifth of cases.
Patients welcomed the service and found it convenient.
The co-operation of reception staff was vital.
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